Universal Tobacco Screening and Opt-Out Treatment Referral Strategy Among Patients Diagnosed With Cancer by Race and Ethnicity

This quality improvement study examines whether a universal screening and opt-out referral model could promote racial and ethnic equity in access and use of tobacco treatment among patients with cancer.


Introduction
Persistent smoking is associated with adverse clinical outcomes in cancer care. 1 Black and Hispanic patients with cancer typically have lower access to and use of tobacco treatment services compared with White patients. 1We examined whether a universal tobacco screening and opt-out tobacco treatment referral model could promote equity in access and use of tobacco treatment among patients with cancer. 1

Methods
This quality improvement study was deemed exempt by the Memorial Sloan Kettering Cancer Center (MSKCC) institutional review board as a retrospective research study and followed the SQUIRE reporting guideline.
We analyzed data from patients diagnosed with cancer at MSKCC between January 1, 2018, and December 31, 2022.In 2011, MSKCC implemented universal screening of tobacco use and adopted an opt-out tobacco treatment referral as standard of care (eFigure in Supplement 1).Patients identified as currently smoking were offered tobacco treatment.Treatment acceptance was defined as scheduling at least 1 session.Patients not currently using tobacco were classified as ineligible.
We analyzed differences in tobacco use, tobacco treatment referral, and acceptance by race and ethnicity using χ 2 and t tests.Race and ethnicity were self-reported, and the categories were derived from the electronic health record.Data were analyzed using R, version 4.3.1 (R Foundation).The significance threshold was a 2-sided P < .05.

Results
As shown in the Figure and Table, among 302 971 patients seen during the study period (58.7% female and 41.3% male; mean [SD] age, 61.9 [14.6] years), the prevalence of current tobacco use was 6.1% and varied significantly by race, with Black or African American patients reporting the highest tobacco use (7.1% compared with 3.8%, 6.2%, and 6.1% for patients of Asian, White, and other race, respectively; P < .001).There were no observed differences in tobacco prevalence between Hispanic or Latino/e/a/x and non-Hispanic or Latino/e/a/x patients; however, prevalence was lower among patients with missing ethnicity data.Of 18 475 patients identified as currently using tobacco, 87.1% were referred for tobacco treatment.Of those referred, 87.6% were eligible, of whom 69.3% were reached for scheduling.Overall acceptance of tobacco treatment among patients reached was 54.8% and was highest among Black or African American patients (66.3% compared with 46.5%, 53.7%, and 58.1% for Asian, White, and other races, respectively; P < .001)and Hispanic or Latino/ e/a/x patients (60.5% compared with 54.3% for non-Hispanic or Latino/e/a/x patients; P = .005).

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Discussion
These findings suggest that a standardized tobacco use assessment with opt-out referral to tobacco treatment in a large cancer care setting is feasible and achieves higher tobacco treatment referral and acceptance rates than typically observed. 2By normalizing tobacco use screening and treatment as essential elements of high-quality cancer care, a universal tobacco screening and opt-out referral strategy may mitigate the stigma associated with patient engagement in tobacco treatment. 3An opt-out referral model may eliminate clinician referral bias and thereby facilitate equitable access to and use of tobacco treatment services 1 among racially and ethnically diverse patients with cancer.
5][6] Despite these encouraging findings, 12.8% of b For this analysis, patients who reported using cannabis only or who had a tobacco use status of never or former at the time of screening were classified as referred to tobacco treatment in error.
c Includes patients referred but not reachable by a tobacco treatment coordinator for scheduling and only received tobacco treatment educational material.

Figure . a
Figure.Universal Tobacco Assessment and Referral Clinical Workflow 302 971 Distinct adult patients (aged >18 years) seeking cancer treatment at MSKCC and screened for tobacco in 2018-2022 a

Table .
Tobacco Use, Referral, and Referral Acceptance Status by Race and Ethnicity